Non-steroidal anti-inflammatory drugs (NSAIDs) are routinely prescribed for mild to moderate pain and are the most commonly prescribed painkilling drugs worldwide. Taken by mouth or injected into a vein, the high concentrations of the drug throughout the body, necessary in order to work at the site of pain and inflammation, can cause unpleasant or even serious side effects. Applied to the skin, so in a topical preparation such as a gel, cream or plaster, they can act where needed to relieve pain without affecting the rest of the body. For superficial painful conditions like sprains, strains and muscle soreness (and where the skin is unbroken) topical NSAIDs offer this clear advantage over taking tablets, as long as they work.

How good are topical NSAIDs?

A Cochrane review has been updated with new research confirming that topical NSAIDs are an effective and safe means of relieving acute musculoskeletal pain in adults. The new evidence also tells us much more than we knew before about which ones work best.

The evidence comes from 61 randomized controlled trials (RCTs) with 8386 people. Several different topical NSAIDs were compared, mostly with placebo in the same carrier – so gel with a drug compared to the gel without a drug, for example. Both would be rubbed into the skin so we know that any effect is not just from rubbing. The reviewers were interested in whether people’s pain was reduced by at least half around seven days after starting treatment.

Here’s what they found:

Topical NSAIDs gave much better pain relief than placebo

Gel formulations of diclofenac, ibuprofen and ketoprofen, and some diclofenac patches, were the most effective. For diclofenac and ketoprofen gels, 7 or 8 people out of 10 with a painful strain, sprain, or muscle pull had much reduced pain after seven days, compared with only 2 or 3 out of 10 with placebo

Other NSAIDs and formulations were better than placebo, but not by as much

About 1 in 20 had a mild and short-lived side effect like redness at the application site and this was the same for topical NSAID or placebo. Side effects like stomach upset were uncommon and there was no difference between topical NSAID and placebo. There were no serious side effects

How reliable is this evidence?

The evidence is high quality

It wasn’t possible to compare topical NSAIDs with each other or with the same oral drug

Recent research has provided us with much more information, especially about topical diclofenac

There is a lot of unpublished data which could influence results in future updates of the review

The bottom line

NSAID gels work best and are a safe alternative to oral drugs for sprains and strains

The reviewers conclude that “topical NSAIDs provided good levels of pain relief in acute conditions such as sprains, strains and overuse injuries, probably similar to that provided by oral NSAIDs.” Sheena Derry, a Senior Research Officer at the University of Oxford and lead author of the review, said “this Cochrane Review offers important news to patients and clinicians; out of the topical NSAID options, gel formulations work best and they are a safe alternative to oral drugs.”

Topical painkillers for chronic pain

Another review by Sheena Derry and colleagues at the Cochrane Pain, Palliative and Supportive Care Group has shown that topical diclofenac solution can provide as effective pain relief for people with knee or hand osteoarthritis as oral diclofenac, but there is no evidence for other chronic painful conditions. Unsurprisingly, topical diclofenac produced more skin reactions but fewer stomach upsets than oral diclofenac.

As for those creams that make your skin red and hot when you rub them on, because they increase the blood flow, Derry and team’s review on these found that there’s no good evidence that they work, with very little data to go on.

See and share the #blogshot

I have also summarised this review as a #blogshot, an image shared on Twitter, Pinterest and Facebook. We have just started to do these and you can see them all here on Pinterest.

About Sarah Chapman

Sarah's work as a Knowledge Broker at Cochrane UK focuses on disseminating Cochrane evidence through social media, including Evidently Cochrane blogs, blogshots and the ‘Evidence for Everyday’ series for nurses, midwives, allied health professionals and patients.
A former registered general nurse, Sarah has a particular interest making evidence accessible and useful to practitioners and to others making decisions about health. Before joining Cochrane, Sarah also worked on systematic reviews for the University of Oxford and the Royal College of Nursing Institute, and obtained degrees in History from the University of Oxford and in the history of women’s health and illness in early modern England (MPhil., University of Reading).

1 Comments on this post

It’s good to see some high quality evidence on the use of topical NSAIDs, I think for years patients have found them useful, but there has often been a scepticism expressed by medics due to the poor data at the time. Hopefully that is now resolved.

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